How To Use HCPCS Code C5278

HCPCS code C5278 describes the application of a low-cost skin substitute graft to various areas of the body, including the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits. This code is used when the total wound surface area is greater than or equal to 100 square centimeters, and for each additional 100 square centimeters of wound surface area or each additional 1% of body area in infants and children. It is important for medical coders to understand the specific details and usage of this code to ensure accurate billing and reimbursement.

1. What is HCPCS C5278?

HCPCS code C5278 is a specific code used to identify the application of a low-cost skin substitute graft to various areas of the body. It is important to note that this code is used when the total wound surface area is greater than or equal to 100 square centimeters, and for each additional 100 square centimeters of wound surface area or each additional 1% of body area in infants and children. This code should be used in addition to the primary procedure code to accurately represent the services provided.

2. Official Description

The official description of HCPCS code C5278 is “Application of low-cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure).” The short description for this code is “Parenteral supp not othrws c.”

3. Procedure

1. The provider begins by assessing the patient’s wound and determining the total wound surface area.
2. If the total wound surface area is greater than or equal to 100 square centimeters, the provider prepares the low-cost skin substitute graft.
3. The provider then applies the graft to the specific areas of the body, including the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits.
4. If the wound surface area exceeds 100 square centimeters, the provider repeats the application process for each additional 100 square centimeters or each additional 1% of body area in infants and children.
5. The procedure is documented and coded accordingly, listing HCPCS code C5278 separately in addition to the primary procedure code.

4. When to use HCPCS code C5278

HCPCS code C5278 should be used when the provider applies a low-cost skin substitute graft to the specified areas of the body and the total wound surface area is greater than or equal to 100 square centimeters. Additionally, this code should be used for each additional 100 square centimeters of wound surface area or each additional 1% of body area in infants and children. It is important to follow the specific eligibility criteria and guidelines for using this code to ensure accurate billing and reimbursement.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code C5278, healthcare providers need to document the details of the procedure, including the total wound surface area, the specific areas of the body where the graft was applied, and any additional wound surface area or body area in infants and children. It is important to accurately code and list HCPCS code C5278 separately in addition to the primary procedure code to reflect the services provided. Proper documentation and coding are crucial for billing and reimbursement purposes.

6. Historical Information and Code Maintenance

HCPCS code C5278 was added to the Healthcare Common Procedure Coding System on January 01, 1985. It has an effective date of January 01, 1996. There have been no maintenance actions taken for this code, as indicated by the action code N, which means no maintenance for this code. It is important for medical coders to stay updated on any changes or revisions to the code to ensure accurate coding and billing.

7. Medicare and Insurance Coverage

HCPCS code C5278 is covered by Medicare and other insurance carriers. The pricing indicator code for this code is 57, which indicates that it is priced by other carriers. The multiple pricing indicator code is A, which means it is not applicable as HCPCS priced under one methodology. It is important to follow the specific pricing guidelines and requirements of Medicare and other insurance carriers when billing for services or supplies associated with HCPCS code C5278.

8. Examples

Here are five examples of when HCPCS code C5278 should be billed:

1. A patient with a wound surface area of 150 square centimeters on their face requires the application of a low-cost skin substitute graft. HCPCS code C5278 should be billed in addition to the primary procedure code.
2. An infant with a wound surface area of 80 square centimeters on their scalp requires the application of a low-cost skin substitute graft. HCPCS code C5278 should not be billed as the total wound surface area does not meet the criteria.
3. A child with a wound surface area of 200 square centimeters on their hands and feet requires the application of a low-cost skin substitute graft. HCPCS code C5278 should be billed for the initial 100 square centimeters and an additional unit of C5278 should be billed for the remaining 100 square centimeters.
4. A patient with a wound surface area of 2% of their body area on their neck requires the application of a low-cost skin substitute graft. HCPCS code C5278 should be billed for the 1% of body area, and an additional unit of C5278 should be billed for the remaining 1% of body area.
5. A patient with a wound surface area of 120 square centimeters on their eyelids requires the application of a low-cost skin substitute graft. HCPCS code C5278 should be billed in addition to the primary procedure code.